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Liu X, Jing B, Graham LA, Liu CK, Lee SJ, Steinman MA, Dave CV, Manja V, Li Y, Fung K, Odden MC. Complex Patterns of Antihypertensive Treatment Changes in Long-Term Care Residents. J Am Med Dir Assoc 2024; 25:105119. [PMID: 38950584 DOI: 10.1016/j.jamda.2024.105119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 04/19/2024] [Accepted: 05/22/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVES Antihypertensive treatment changes are common in long-term care residents, yet data on the frequency and predictors of changes are lacking. We described the patterns of antihypertensive changes and examined the triggering factors. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS A total of 24,870 Department of Veterans Affairs (VA) nursing home residents aged ≥65 years with long-term stays (≥180 days) from 2006 to 2019. METHODS We obtained data from the VA Corporate Data Warehouse. Based on Bar Code Medication Administration medication data, we defined 2 types of change events in 180 days of admission: deprescribing (reduced number of antihypertensives or dose reduction of ≥30% compared with the previous week and maintained for at least 2 weeks) and intensification (opposite of deprescribing). Mortality was identified within 2 years after admission. RESULTS More than 85% of residents were prescribed antihypertensives and 68% of them experienced ≥1 change event during the first 6 months of the nursing home stay. We categorized residents into 10 distinct patterns: no change (27%), 1 deprescribing (11%), multiple deprescribing (5%), 1 intensification (10%), multiple intensification (7%), 1 deprescribing followed by 1 intensification (3%), 1 intensification followed by 1 deprescribing (4%), 3 changes with mixed events (7%), >3 changes with mixed events (10%), and no antihypertensive use (15%). Treatment changes were more frequent in residents with better physical function and/or cognitive function. Potentially triggering factors differed by the type of antihypertensive change: incident high blood pressure and cardiovascular events were associated with intensification, and low blood pressure, weight loss, and falls were associated with deprescribing. Death occurred in 7881 (32%) residents over 2 years. The highest mortality was for those without antihypertensive medication (incidence = 344/1000 person-years). CONCLUSIONS AND IMPLICATIONS Patterns of medication changes existing in long-term care residents are complex. Future studies should explore the benefits and harms of these antihypertensive treatment changes.
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Affiliation(s)
- Xiaojuan Liu
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA; Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA.
| | - Bocheng Jing
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA, USA; Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Laura A Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA; Stanford-Surgery Policy Improvement Research Education Center, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Christine Kee Liu
- Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA; Section of Geriatrics, Division of Primary Care and Population Health, Stanford University, School of Medicine, Stanford, CA, USA
| | - Sei J Lee
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA, USA; Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Michael A Steinman
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA, USA; Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Chintan V Dave
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA; Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USA
| | - Veena Manja
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA; Department of Health Policy, Stanford University, Stanford, CA, USA
| | - Yongmei Li
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Kathy Fung
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA, USA; Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Michelle C Odden
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA; Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
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Schleiden LJ, Klima G, Rodriguez KL, Ersek M, Robinson JE, Hickson RP, Smith D, Cashy J, Sileanu FE, Thorpe CT. Clinician and Family Caregiver Perspectives on Deprescribing Chronic Disease Medications in Older Nursing Home Residents Near the End of Life. Drugs Aging 2024; 41:367-377. [PMID: 38575748 PMCID: PMC11021174 DOI: 10.1007/s40266-024-01110-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/06/2024]
Abstract
INTRODUCTION Nursing home (NH) residents with limited life expectancy (LLE) who are intensely treated for hyperlipidemia, hypertension, or diabetes may benefit from deprescribing. OBJECTIVE This study sought to describe NH clinician and family caregiver perspectives on key influences on deprescribing decisions for chronic disease medications in NH residents near the end of life. METHODS We recruited family caregivers of veterans who recently died in a Veterans Affairs (VA) NH, known as community living centers (CLCs), and CLC healthcare clinicians (physicians, nurse practitioners, physician assistants, pharmacists, registered nurses). Respondents completed semi-structured interviews about their experiences with deprescribing statin, antihypertensive, and antidiabetic medications for residents near end of life. We conducted thematic analysis of interview transcripts to identify key themes regarding influences on deprescribing decisions. RESULTS Thirteen family caregivers and 13 clinicians completed interviews. Key themes included (1) clinicians and caregivers both prefer to minimize drug burden; (2) clinical factors strongly influence deprescribing of chronic disease medications, with differences in how clinicians and caregivers weigh specific factors; (3) caregivers trust and rely on clinicians to make deprescribing decisions; (4) clinicians perceive caregiver involvement and buy-in as essential to deprescribing decisions, which requires time and effort to obtain; and (5) clinicians perceive conflicting care from other clinicians as a barrier to deprescribing. CONCLUSIONS Findings suggest a need for efforts to encourage communication with and education for family caregivers of residents with LLE about deprescribing, and to foster better collaboration among clinicians in CLC and non-CLC settings.
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Affiliation(s)
- Loren J Schleiden
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA.
| | - Gloria Klima
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
| | - Keri L Rodriguez
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
| | - Mary Ersek
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Jacob E Robinson
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Ryan P Hickson
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Dawn Smith
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - John Cashy
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA
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Roh E, Cota E, Lee JP, Madievsky R, Eskildsen MA. Polypharmacy in Nursing Homes. Clin Geriatr Med 2022; 38:653-666. [DOI: 10.1016/j.cger.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Odden MC, Li Y, Graham LA, Steinman MA, Marcum ZA, Liu CK, Jing B, Fung KZ, Peralta CA, Lee SJ. Trends in blood pressure diagnosis, treatment, and control among VA nursing home residents, 2007-2018. J Am Geriatr Soc 2022; 70:2280-2290. [PMID: 35524763 PMCID: PMC9378662 DOI: 10.1111/jgs.17821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/09/2022] [Accepted: 03/20/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Inadequate treatment of high blood pressure (BP) can lead to preventable adverse events in nursing home residents, while excessive treatment can lead to associated harms. METHODS Data were extracted from the VA electronic health record and Bar Code Medication Administration system on 40,079 long-term care residents aged ≥65 years from October 2006 through September 2018 (FY2007-2018). Hypertension prevalence at admission was identified by ICD code(s) in the year prior, and antihypertensive medication use was defined as administration ≥50% of days. BP measures were averaged over 2-year epochs. RESULTS The age-standardized prevalence of hypertension diagnosis at admission increased from 75.2% in FY2007-2008 to 85.1% in FY2017-2018 (p-value for trend <0.001). Rates of BP treatment and control among residents with hypertension at admission declined slightly over time (p-values for trend <0.001) but remained high (80.3% treated in FY2017-2018, 80.1% with average BP <140/90 mmHg). The age-adjusted prevalence of chronic low BP (average <90/60 mmHg) also declined from 11.1% in FY2007-2008 to 4.7% in FY2017-2018 (p-value for trend <0.001). Persons identified as Black race or Hispanic ethnicity and those with a history of diabetes, stroke, and renal disease were less likely to have an average BP <140/90 mmHg. CONCLUSIONS Hypertension is well controlled in VA nursing homes, and recent trends of less intensive BP control were accompanied by a lower prevalence of chronic low BP. Nonetheless, some high-risk populations have average BP levels >140/90 mmHg. Future research is needed to better understand the benefits and harms of BP control in nursing home residents.
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Affiliation(s)
- Michelle C Odden
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA,Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
| | - Yongmei Li
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA
| | - Laura A. Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA
| | - Michael A. Steinman
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA,Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA
| | | | - Christine K. Liu
- Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA,Department of Medicine, Division of Primary Care and Population Health, Stanford University, Stanford CA
| | - Bocheng Jing
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA
| | - Kathy Z. Fung
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA
| | - Carmen A Peralta
- Kidney Health Research Collaborative, University of California San Francisco and San Francisco VA Medical Center, San Francisco, CA,Cricket Health, Inc
| | - Sei J Lee
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA,Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA
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Bahat G, İlhan B, Tufan A, Kılıç C, Karan MA, Petrovic M. Hypotension Under Antihypertensive Treatment and Incident Hospitalizations of Nursing Home Residents. Drugs Aging 2022; 39:477-484. [PMID: 35701577 DOI: 10.1007/s40266-022-00951-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Hypertension is the most prevalent chronic disease in older adults. Antihypertensive drug use increases with aging. In some studies, hypotension developing under antihypertensive medication use has been indicated as a potential risk factor for morbidity and mortality in older adults. Our objective was to assess the relationship between hypotension under antihypertensive treatment and incident hospitalization of nursing home residents. METHODS We detailed blood pressure measurements of the previous 1-year period that were noted regularly at 2-week intervals and studied their mean values. The systolic blood pressure (SBP) and diastolic blood pressure (DBP) thresholds to define low SBP (≤ 110 mm Hg) and DBP (≤ 65 mm Hg) were derived from our previous study. We noted demographics, number of co-morbidities and regular medications, mobility status, and nutritional assessment via the Mini Nutritional Assessment Short Form. RESULTS We included 253 participants (66% male, mean age 75.7 ± 8.7 years). The prevalence of low SBP (≤ 110 mmHg) and low DBP (≤ 65 mmHg) was 34.8% and 15.8%, respectively. Among residents, 4% were bedridden, 15.8% wheelchair bound, 14.5% needing assistance for reduced mobility, and 62.7% were ambulatory. At a median of 15 months of follow-up, hospitalization incidence from any cause was 50.8% (n = 134). Incident hospitalization was more common in the group that had low DBP (odds ratio = 3.06; 95% confidence interval 1.02-9.15; p = 0.04) after adjusting for age, number of comorbidities and medications, mobility status, and nutritional status. Low SBP was not associated with hospitalization. CONCLUSIONS The low DBP (≤ 65 mm Hg) during the previous year was associated with incident hospitalization of nursing home residents after adjustment for several factors. These findings indicate that lower DBP may be a causative factor for incident hospitalization. We need further studies to explore whether a correction of diastolic hypotension may decrease the hospitalization risk in this vulnerable population.
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Affiliation(s)
- Gülistan Bahat
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, Istanbul, 34390, Türkiye.
| | - Birkan İlhan
- Department of Internal Medicine, Division of Geriatrics, Sisli Hamidiye Etfal Teaching and Research Hospital, University of Health Sciences Türkiye, Istanbul, Türkiye
| | - Asli Tufan
- Department of Internal Medicine, Division of Geriatrics, Marmara University Medical School, Istanbul, Türkiye
| | - Cihan Kılıç
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, Istanbul, 34390, Türkiye
| | - Mehmet Akif Karan
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, Istanbul, 34390, Türkiye
| | - Mirko Petrovic
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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Kraut R, Lundby C, Babenko O, Kamal A, Sadowski CA. Antihypertensive medication in frail older adults: A narrative review through a deprescribing lens. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 17:100166. [PMID: 38559885 PMCID: PMC10978346 DOI: 10.1016/j.ahjo.2022.100166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 04/04/2024]
Abstract
Purpose of review The management of hypertension in frail older adults remains controversial, as these patients are underrepresented in clinical trials and practice guidelines. Overtreatment may cause harm while undertreatment may lead to greater risk of cardiovascular events. Our research aims to examine this controversy and provide guidance regarding deprescribing decisions in frail older adults. Results Current evidence suggests that there may be minimal cardiovascular benefit and significant harm of antihypertensive medication in the frail older adult population. A minority of hypertension guidelines provide sufficient recommendations for frail older adults, and there are limited tools available to guide clinical decision-making. Conclusion Randomized controlled trials and well-designed observational studies are needed to confirm the benefit-to-harm relationship of antihypertensive medication in frail older adults. Decision tools that comprehensively address antihypertensive deprescribing would be advantageous to help clinicians with hypertension management in this population. Clinicians should engage in shared decision-making with the patient and family to ensure that decisions regarding antihypertensive deprescribing best meet the needs of all involved.
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Affiliation(s)
- Roni Kraut
- Department of Family Medicine, University of Alberta, Edmonton, Canada
| | - Carina Lundby
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense C, Denmark
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Oksana Babenko
- Department of Family Medicine, University of Alberta, Edmonton, Canada
| | - Ahmad Kamal
- Faculty of Science, University of Alberta, Edmonton, Canada
| | - Cheryl A. Sadowski
- Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
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Arrieta H, Rezola-Pardo C, Gil J, Kortajarena M, Zarrazquin I, Echeverria I, Mugica I, Limousin M, Rodriguez-Larrad A, Irazusta J. Effects of an individualized and progressive multicomponent exercise program on blood pressure, cardiorespiratory fitness, and body composition in long-term care residents: Randomized controlled trial. Geriatr Nurs 2022; 45:77-84. [PMID: 35339954 DOI: 10.1016/j.gerinurse.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/10/2022] [Accepted: 03/12/2022] [Indexed: 11/04/2022]
Abstract
This study analyzed the effects of an individualized and progressive multicomponent exercise program on blood pressure, cardiorespiratory fitness, and body composition in long-term care residents. This was a single-blind, multicenter, randomized controlled trial performed in 10 long-term care settings and involved 112 participants. Participants were randomly assigned to a control group or an intervention group. The control group participated in routine activities; the intervention group participated in a six-month individualized and progressive multicomponent exercise program focused on strength, balance, and walking recommendations. The intervention group maintained peak VO2, oxygen saturation, and resting heart rate, while the control group showed a significant decrease in peak VO2 and oxygen saturation and an increase in resting heart rate throughout the six-month period. Individualized and progressive multicomponent exercise programs comprising strength, balance, and walking recommendations appear to be effective in preventing cardiorespiratory fitness decline in older adults living in long-term care settings.
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Affiliation(s)
- Haritz Arrieta
- Department of Nursing II, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Begiristain Doktorea Pasealekua 105, E-20014 Donostia-San Sebastián, Gipuzkoa, Spain..
| | - Chloe Rezola-Pardo
- Department of Physiology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Barrio Sarriena s/n, E-48940 Leioa, Bizkaia, Spain
| | - Javier Gil
- Department of Physiology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Barrio Sarriena s/n, E-48940 Leioa, Bizkaia, Spain
| | - Maider Kortajarena
- Department of Nursing II, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Begiristain Doktorea Pasealekua 105, E-20014 Donostia-San Sebastián, Gipuzkoa, Spain
| | - Idoia Zarrazquin
- Department of Nursing II, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Begiristain Doktorea Pasealekua 105, E-20014 Donostia-San Sebastián, Gipuzkoa, Spain
| | - Iñaki Echeverria
- Department of Physiology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Barrio Sarriena s/n, E-48940 Leioa, Bizkaia, Spain.; Department of Physical Education and Sport, Faculty of Education and Sport, University of the Basque Country (UPV/EHU), Portal de Lasarte 71, E-01007 Vitoria-Gasteiz (Araba), Spain
| | - Itxaso Mugica
- Department of Nursing II, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Begiristain Doktorea Pasealekua 105, E-20014 Donostia-San Sebastián, Gipuzkoa, Spain
| | - Marta Limousin
- Uzturre Asistentzia Gunea, San Joan Kalea 4, E-20400 Tolosa (Gipuzkoa), Spain
| | - Ana Rodriguez-Larrad
- Department of Physiology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Barrio Sarriena s/n, E-48940 Leioa, Bizkaia, Spain
| | - Jon Irazusta
- Department of Physiology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), Barrio Sarriena s/n, E-48940 Leioa, Bizkaia, Spain
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Chao CT, Lee SY, Wang J, Chien KL, Huang JW. Frailty increases the risk for developing urinary tract infection among 79,887 patients with diabetic mellitus and chronic kidney disease. BMC Geriatr 2021; 21:349. [PMID: 34098883 PMCID: PMC8186134 DOI: 10.1186/s12877-021-02299-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 05/04/2021] [Indexed: 02/07/2023] Open
Abstract
Background Patients with diabetic mellitus (DM) and chronic kidney disease (CKD) are at an increased risk of urinary tract infection (UTI) due to their altered immunological integrity. These patients are similarly prone to developing frailty, a state of cumulative health deficits involving multiple domains and leading to adverse outcomes. Whether frailty predisposes affected individuals to UTI among patients with DM and CKD remains unclear. Methods A population-based cohort of patients with DM and CKD (n = 79,887) were assembled from the Longitudinal Cohort of Diabetes Patients, with their baseline frailty status measured by a modified FRAIL scale. We analyzed their risk of developing UTI depending on their severity of frailty, after accounting demographic profiles, lifestyle factors, comorbidities, concurrent medications, and major interventions. A secondary analysis focused on the risk of urosepsis related to frailty. Results Among all participants, 36.1 %, 50.3 %, 12.8 %, and 0.8 % did not have or had 1, 2, and ≥ 3 FRAIL items, respectively, at baseline. After 3.51 years, 11,175 UTI events occurred. Kaplan-Meier analysis showed that participants with DM, CKD and an increasing number of FRAIL items had successively higher incidence of UTI than those without any FRAIL items (log rank p < 0.001). Cox proportional hazard modeling revealed that after accounting for all confounders, those with more severe frailty exhibited a significantly higher risk of incident UTI (for groups of 1, 2, and ≥ 3 FRAIL items, hazard ratio 1.19, 1.24, and 1.43, respectively; all p < 0.001) than those without. An 11 % risk elevation for UTI could be observed for every FRAIL item increase. Participants with more severe frailty exhibited a trend of having higher risk of urosepsis as well. Conclusions Having frailty predicted a higher risk of developing UTI in the future in patients with DM and CKD. It would be prudent to screen for frailty in these patients and provide optimal frailty-directed management to attenuate their risk of UTI and improve their outcomes.
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Affiliation(s)
- Chia-Ter Chao
- Nephrology division, Department of Internal Medicine, National Taiwan University Hospital BeiHu Branch, Taipei, Taiwan.,Geriatric and Community Medicine Research Center, National Taiwan University Hospital BeiHu Branch, Taipei, Taiwan.,Graduate Institute of Toxicology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Szu-Ying Lee
- Nephrology division, Department of Internal Medicine, National Taiwan University Hospital Yunlin branch, Yunlin county, Taiwan
| | - Jui Wang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Kuo-Liong Chien
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Jenq-Wen Huang
- Nephrology division, Department of Internal Medicine, National Taiwan University Hospital Yunlin branch, Yunlin county, Taiwan.
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Chao CT, Lee SY, Wang J, Chien KL, Huang JW. Frailty increases the risk for developing urinary tract infection among 79,887 patients with diabetic mellitus and chronic kidney disease. BMC Geriatr 2021. [PMID: 34098883 DOI: 10.1186/s12877-021-02299-3[publishedonlinefirst:2021/06/09]] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Patients with diabetic mellitus (DM) and chronic kidney disease (CKD) are at an increased risk of urinary tract infection (UTI) due to their altered immunological integrity. These patients are similarly prone to developing frailty, a state of cumulative health deficits involving multiple domains and leading to adverse outcomes. Whether frailty predisposes affected individuals to UTI among patients with DM and CKD remains unclear. METHODS A population-based cohort of patients with DM and CKD (n = 79,887) were assembled from the Longitudinal Cohort of Diabetes Patients, with their baseline frailty status measured by a modified FRAIL scale. We analyzed their risk of developing UTI depending on their severity of frailty, after accounting demographic profiles, lifestyle factors, comorbidities, concurrent medications, and major interventions. A secondary analysis focused on the risk of urosepsis related to frailty. RESULTS Among all participants, 36.1 %, 50.3 %, 12.8 %, and 0.8 % did not have or had 1, 2, and ≥ 3 FRAIL items, respectively, at baseline. After 3.51 years, 11,175 UTI events occurred. Kaplan-Meier analysis showed that participants with DM, CKD and an increasing number of FRAIL items had successively higher incidence of UTI than those without any FRAIL items (log rank p < 0.001). Cox proportional hazard modeling revealed that after accounting for all confounders, those with more severe frailty exhibited a significantly higher risk of incident UTI (for groups of 1, 2, and ≥ 3 FRAIL items, hazard ratio 1.19, 1.24, and 1.43, respectively; all p < 0.001) than those without. An 11 % risk elevation for UTI could be observed for every FRAIL item increase. Participants with more severe frailty exhibited a trend of having higher risk of urosepsis as well. CONCLUSIONS Having frailty predicted a higher risk of developing UTI in the future in patients with DM and CKD. It would be prudent to screen for frailty in these patients and provide optimal frailty-directed management to attenuate their risk of UTI and improve their outcomes.
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Affiliation(s)
- Chia-Ter Chao
- Nephrology division, Department of Internal Medicine, National Taiwan University Hospital BeiHu Branch, Taipei, Taiwan
- Geriatric and Community Medicine Research Center, National Taiwan University Hospital BeiHu Branch, Taipei, Taiwan
- Graduate Institute of Toxicology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Szu-Ying Lee
- Nephrology division, Department of Internal Medicine, National Taiwan University Hospital Yunlin branch, Yunlin county, Taiwan
| | - Jui Wang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Kuo-Liong Chien
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Jenq-Wen Huang
- Nephrology division, Department of Internal Medicine, National Taiwan University Hospital Yunlin branch, Yunlin county, Taiwan.
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Vu M, Sileanu FE, Aspinall SL, Niznik JD, Springer SP, Mor MK, Zhao X, Ersek M, Hanlon JT, Gellad WF, Schleiden LJ, Thorpe JM, Thorpe CT. Antihypertensive Deprescribing in Older Adult Veterans at End of Life Admitted to Veteran Affairs Nursing Homes. J Am Med Dir Assoc 2020; 22:132-140.e5. [PMID: 32723537 DOI: 10.1016/j.jamda.2020.05.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/26/2020] [Accepted: 05/26/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Geriatric palliative care approaches support deprescribing of antihypertensives in older nursing home (NH) residents with limited life expectancy and/or advanced dementia (LLE/AD) who are intensely treated for hypertension (HTN), but information on real-world deprescribing patterns in this population is limited. We examined the incidence and factors associated with antihypertensive deprescribing. DESIGN National, retrospective cohort study. SETTING AND PARTICIPANTS Older Veterans with LLE/AD and HTN admitted to VA NHs in fiscal years 2009-2015 with potential overtreatment of HTN at admission, defined as receiving at least 1 antihypertensive class of medications and mean daily systolic blood pressure (SBP) <120 mm Hg. MEASURES Deprescribing was defined as subsequent dose reduction or discontinuation of an antihypertensive for ≥7 days. Competing risk models assessed cumulative incidence and factors associated with deprescribing. RESULTS Within our sample (n = 10,574), cumulative incidence of deprescribing at 30 days was 41%. Veterans with the greatest level of overtreatment (ie, multiple antihypertensives and SBP <100 mm Hg) had an increased likelihood (hazard ratio 1.75, 95% confidence interval 1.59, 1.93) of deprescribing vs those with the lowest level of overtreatment (ie, one antihypertensive and SBP ≥100 to <120 mm Hg). Several markers of poor prognosis (ie, recent weight loss, poor appetite, dehydration, dependence for activities of daily living, pain) and later admission year were associated with increased likelihood of deprescribing, whereas cardiovascular risk factors (ie, diabetes, congestive heart failure, obesity), shortness of breath, and admission source from another NH or home/assisted living setting (vs acute hospital) were associated with decreased likelihood. CONCLUSIONS AND IMPLICATIONS Real-world deprescribing patterns of antihypertensives among NH residents with HTN and LLE/AD appear to reflect variation in recommendations for HTN treatment intensity and individualization of patient care in a population with potential overtreatment. Factors facilitating deprescribing included treatment intensity and markers of poor prognosis. Comparative effectiveness and safety studies are needed to guide clinical decisions around deprescribing and HTN management.
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Affiliation(s)
- Michelle Vu
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Veteran Affairs Pharmacy Benefits Management Service, Center for Medication Safety, Hines, IL, USA
| | - Florentina E Sileanu
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA
| | - Sherrie L Aspinall
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Veteran Affairs Pharmacy Benefits Management Service, Center for Medication Safety, Hines, IL, USA; Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Joshua D Niznik
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of North Carolina School of Medicine, Chapel Hill, NC, USA; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Sydney P Springer
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of New England College of Pharmacy, Portland, ME, USA
| | - Maria K Mor
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA
| | - Xinhua Zhao
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA
| | - Mary Ersek
- Corporal Michael J. Crescenz Veterans Affair's Medical Center, Center for Health Equity Research and Promotion, Philadelphia, PA, USA; University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Joseph T Hanlon
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA; University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Loren J Schleiden
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Joshua M Thorpe
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Carolyn T Thorpe
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA.
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